Nursing Care Plan for Rheumatoid Arthritis

Nursing diagnosis: acute/chronic Pain related to injuring agents—distention of tissues by accumulation of fluid/inflammatory process, destruction of joint

Possibly evidenced by
Reports of pain, discomfort; fatigue
Self-narrowed focus
Distraction behaviors; autonomic responses
Guarding, protective behavior

Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain is relieved or controlled.
Appear relaxed and able to sleep, rest, and participate in activities appropriately.
Pain Control
Follow prescribed pharmacological regimen.
Incorporate relaxation skills and diversional activities into pain control program.

Nursing intervention with rationale:
1. Investigate reports of pain, noting location, and intensity using a scale of 0 to 10 or similar. Note precipitating factors and nonverbal pain cues.
Rationale: Self-report should be the primary source of pain assessment in determining pain management needs and effectiveness of program.

2. Recommend or provide firm mattress or bedboard and small pillow. Elevate linens with bed cradle as needed.
Rationale: Soft or sagging mattress and large pillows prevent maintenance of proper body alignment, placing stress on affected joints. Elevation of bed linens reduces pressure on inflamed, painful joints.

3. Suggest client assume position of comfort while in bed or sitting in chair. Promote bedrest when indicated, but resume movement as soon as possible.
Rationale: In severe disease or acute exacerbation, total bedrest may be necessary until objective and subjective improvements are noted to limit pain and injury to joint. Note: Immobility is known to worsen arthritis pain and stiffness.

4. Place and monitor use of pillows, sandbags, trochanter rolls, and splints.
Rationale: Rests painful joints and maintains neutral position. Note: Use of splints can decrease pain and may reduce damage to joint; however, prolonged inactivity can result in loss of joint mobility and function.

5. Encourage frequent changes of position. Assist client to move in bed, supporting affected joints above and below, avoiding jerky movements.
Rationale: Prevents general fatigue and joint stiffness. Stabilizes joint, decreasing joint movement and associated pain.

6. Recommend that client take warm bath or shower on arising and/or at bedtime. Apply warm, moist compresses to affected joints several times a day. Monitor water temperature of compresses, baths, and so on.
Rationale: Heat promotes muscle relaxation and mobility, decreases pain, and relieves morning stiffness. Sensitivity to heat may be diminished and dermal injury may occur.

7. Encourage use of stress management techniques, such as progressive relaxation, biofeedback, visualization, guided imagery, self-hypnosis, and controlled breathing. Provide Therapeutic Touch.
Rationale: Promotes relaxation, provides sense of control, and may enhance coping abilities.

8. Involve client in diversional activities appropriate for individual situation.
Rationale: Refocuses attention, provides stimulation, and enhances selfesteem and feelings of general well-being.

9. Medicate before planned activities and exercises, as indicated.
Rationale: Promotes relaxation, reduces muscle tension and spasms, facilitating participation in therapy.

10. Monitor for development of skin rash in clients usingcyclo-oxgenase-2 (COX-2) inhibitors, especially those allergic to sulfur.
Rationale: Severe, life-threatening skin reactions, such as toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme, may develop within the first 2 weeks of treatment or later on, indicating need for prompt discontinuation of medication.

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Nursing Care Plan for Cancer

Nursing diagnosis: acute/chronic Pain related to disease process—compression or destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a
nerve pathway, inflammation, metastasis to bones; side effects of various cancer therapy agents

Possibly evidenced by
Reports of pain
Self-focusing, narrowed focus
Alteration in muscle tone; facial mask of pain
Distraction/guarding behaviors
Autonomic responses, restlessness (acute pain)

Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report maximal pain relief or control with minimal interference with activities of daily living (ADLs).
Pain Control
Follow prescribed pharmacological regimen.
Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing intervention with rationale:
1. Determine pain history, for example, location of pain, frequency, duration, and intensity using a rating scale (scale of 0–10), or verbal rating scale—“no pain” to “excruciating pain”; and relief measures used. Believe client’s report.
Rationale: Information provides baseline data to evaluate need for, and effectiveness of, interventions. Pain of more than 6 months’ duration constitutes chronic pain, which may affect therapeutic choices. Recurrent episodes of acute pain can occur within chronic pain, requiring increased level of intervention. Note: The pain experience is an individualized one composed of both physical and emotional responses.

2. Determine timing and precipitants of “breakthrough” pain when using around-the-clock agents, whether oral, intravenous (IV), topical, transmucosal, epidural, or patch medications.
Rationale: Pain may occur near the end of the dose interval, indicating need for higher dose or shorter dose interval. Pain may be precipitated by identifiable triggers, or occur spontaneously, requiring use of short half-life agents for rescue or supplemental doses.

3. Evaluate painful effects of particular therapies, such as surgery, radiation, chemotherapy, or biotherapy. Provide information to client and SO about what to expect.
Rationale: A wide range of discomforts are common such as incisional pain, burning skin, low back pain, mouth sores, or headaches, depending on the procedure or agent being used. Pain is also associated with invasive procedures to diagnose or treat cancer.

4. Provide nonpharmacological comfort measures such as massage, repositioning, and back rub; as well as diversional activities, such as music, reading, and TV.
Rationale: Promotes relaxation and helps refocus attention.

5. Encourage use of stress management skills and complementary therapies such as relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and Therapeutic Touch.
Rationale: Enables client to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases client’s focus on self, which in turn increases the level of pain.

6. Provide cutaneous stimulation, such as heat and cold packs, or massage.
Rationale: May decrease inflammation, muscle spasms, reducing associated pain.

7. Be aware of barriers to cancer pain management related to client, as well as the healthcare system.
Rationale: Clients may be reluctant to report pain for reasons such as fear that disease is worse; worry about unmanageable side effects of pain medications; belief that pain has meaning, such as “God wills it,” they should overcome it; or that pain is merited or deserved for some reason. Healthcare system problems include factors such as inadequate assessment of pain, concern about controlled substances or client addiction, inadequate reimbursement, and cost of treatment modalities.

8. Administer analgesics, as indicated, for example: Opioids such as codeine, morphine (MSContin, Kadian), oxycodone (oxycontin), hydrocodone (Vicodin), hydromorphone (Dilaudid), methadone (Dolophine), fentanyl (Duragesic, Actiq, Fentora), or oxymorphone (Numorphan, Opana
Rationale: Effective for localized and generalized moderate to severe pain, with long-acting or controlled-release forms available. Routes of administration include oral; transmucosal; transdermal; nasal; rectal; and subcutaneous, IV, epidural, and intrathecal infusions, which may be delivered via patientcontrolled analgesia (PCA). Fentanyl citrate (Oralet) is available as a transmucosal agent that is absorbed through the mucosa of the inner cheek. Note: Intramuscular (IM) route is not recommended for pain medications because absorption is not reliable, in addition to being painful and inconvenient.

9. Prepare for and assist with procedures such as nerve blocks, cordotomy, commissural myelotomy, or radiation therapy.
Rationale: May be used in severe, intractable pain unresponsive to other measures. Note: Radiation is especially useful for bone metastasis and may provide fast onset of pain relief even with only one treatment.

10. Refer to structured support group, psychiatric clinical nurse specialist, psychologist, or spiritual advisor for counseling, as indicated.
Rationale: May be necessary to reduce anxiety and enhance client’s coping skills, decreasing level of pain. Note: Hypnosis can heighten awareness and help to focus concentration to decrease perception of pain.

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Nursing Care Plan for Pediatric Considerations

Nursing diagnosis: acute/chronic Pain related to injuring agents—biological, chemical, physical, psychological

Possibly evidenced by
Verbal cues
Changes in appetite and eating, sleep pattern
Guarding, protective behavior; restlessness, moaning, crying, irritability
Autonomic responses

Desired Outcomes/Evaluation Criteria—Child Will
Pain Level
Report or indicate pain is relieved or controlled.
Manifest decreased restlessness and irritability.
Demonstrate age-appropriate blood pressure (BP), pulse, and respiratory rates.
Pain Disruptive Effects
Participate in usual activities within level of ability.

Nursing intervention with rationale:
1. Perform routine comprehensive pain assessment, including location, characteristics, onset, duration, frequency, quality, and severity using some type of rating scale, such as numbers or visual analog, facial expressions, or color scale.
Rationale: Assessment of children involves observational skills and may require enlisting the aid of parent or caregiver to clarify cues and verbalizations. Choice of rating scale is dependent on age and developmental level (Suresh, 2002).

2. Accept child’s description of pain, noting precipitating, exacerbating, and relieving factors.
Rationale: Pain is subjective and cannot be experienced by others. Note: In presence of chronic pain situation, use of a pain diary may be appropriate for adolescents (Suresh, 2002).

3. Investigate changes in frequency or description of pain.
Rationale: May signal worsening of condition or development of complications.

4. Observe for guarding, rigidity, crying, and restlessness.
Rationale: Nonverbal expressions, body movement, and behavioral state may signal pain or changes in pain severity, especially in infants and younger children (Suresh, 2002).

5. Monitor heart rate, BP using correctly sized cuff, and respiratory rate, noting age-appropriate normals and variations.
Rationale: Changes in autonomic responses may indicate increased pain before child verbalizes. Note: Autonomic responses change with acute pain, not chronic pain. BP may be lower than normal or higher than normal.

6. Note location and type of surgical incisions or trauma.
Rationale: Influences degree and severity of pain manifestations.

7. Identify ways to avoid or minimize pain, such as splinting surgical incisions during coughing, sleeping on a firm mattress, or wearing brace on sprains.
Rationale: Many factors may reduce pain intensity based on specific situation. Child can quickly learn and use such pain management techniques, enhancing sense of control as well as comfort.

8. Review procedures and expectations and tell child when it will hurt. Provide distraction during painful procedures, such as deep breathing or counting, or looking at something that interests child.
Rationale: Although the procedure may still be stressful, child will find it easier to handle if he or she knows what to expect and has developed coping strategies.

9. Collaborate in treatment of underlying conditions or disease process.
Rationale: Treating cause, when possible, can eliminate pain.

10. Administer medications, such as opioid and nonsteroidal analgesics, as indicated. Use multiple routes to deliver analgesia, such as oral, nebulized, transdermal, or patientcontrolled analgesia (PCA), as indicated by current situation.
Rationale: Depending on the cause and type of pain, as well as its chronicity, various means of pain management may be needed to overcome or control pain.

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